A Case Study of Occupational Therapy in Acute Myocardial Infarction Patient

Abstract

The increasing prevalence of coronary heart disease and heart failure, as well as their multiple consequences on individual level, in terms of functional limitations and occupational participation restrictions, including socio-economic challenges, impose the implementation of new effective methods and strategies for prevention, treatment and rehabilitation. More studies revealed that a comprehensive therapeutic approach of coronary patient, which includes also disease’s self-management through counselling and therapeutic education interventions, contributes significantly to reducing morbidity and mortality of this type and the risk of sub-optimal patients’ recovery. The aim of this study was to present a strategy for increasing self-efficacy of therapeutic management interventions based on the patient's occupational needs in the context of his living environment. Thus, we proposed, implemented and validated a six weeks intervention plan for the clinical case of a 54 years old man with post myocardial infarction status. Our strategy consisted in teaching the patient how to identify and solve the various occupational problems he is facing, by using a problem solving process approach. In order to evaluate the results, a series of assessments were conducted: self-perception of occupational performance (using COPM), heart rate, level of perceived intensity during physical activity (Borg RPE Scale) and anxiety level. In conclusion, the favourable evolution of the patient, as a result of our proposed therapeutic intervention, provides clinical evidence supporting the idea that the principle of client-centred practice in the context of occupational therapy is a reliable resource for promoting and improving disease selfmanagement in cardiac rehabilitation.

Keywords: Case studyoccupational therapymyocardial infarction

Introduction

The increasing prevalence of coronary heart disease and heart failure, as well as their multiple

consequences on individual level, in terms of functional limitations and occupational participation

restrictions, including socio-economic challenges, impose the implementation of new effective methods

and strategies for prevention, treatment and rehabilitation.

Cardiovascular diseases remain a leading cause of morbidity and mortality, despite improvements

in outcomes (European Society of Cardiology, 2016) and many survivors suffer lasting disabilities and

medical complications, having at least one comorbidity (Mampuya, 2012).

The survivors of myocardial infarction usually experience serious deficiencies of motor, cognitive

and sensory functions, causing a decreased quality of life and life expectancy, and in addition, a

substantial burden on national economies (Drosselmeyer et al., 2014). Cardiac rehabilitation is a

necessity, especially when it comes to providing appropriate and affordable health services, to assist the

patients’ specific needs during the transition period between the end of hospitalization and reintegration

in their home environment (Aronsson et al., 2009).

Considering the epidemiology of CVDs and also the outcomes from the specialty literature, it is

estimated that the necessity for tangible programs of secondary prevention and cardiac rehabilitation will

increase in the future because people with chronic illnesses are especially vulnerable, requiring

continuing recovery assistance (Savage et. al., 2011; Wang, Zhao & Zang, 2014; Lay et al., 2015).

Theoretical Foundation and Related Literature

A lot of recommendations on lifestyle changing and limiting risk factors are gathered in the

clinical guidelines for cardiac patients, but we found a considerable oversight of the references on how

the patient can continue with the meaningful activities he had before the myocardial infarction (Tooth &

McKenna, 1996; Servey & Stephens, 2016). Particularly, the indications are vague and inconsistent with

the stage of recovery, thereby restricting a timely return of the person to earlier occupational routines

(Désiron et al., 2011).

Consequently, more studies revealed that a comprehensive therapeutic approach of coronary

patient, which includes also disease’s self-management through counselling and therapeutic education

interventions, contributes significantly to reducing morbidity and mortality of this type and the risk of

sub-optimal patients’ recovery (Piepoli et al., 2014, 2016). The emphasis in this type of approach is on

increasing self-efficacy and his confidence in solving problems and making decisions. It is encouraged

the partnership between the patient and the therapist and also patient’s access to relevant information that

can empower him to take the necessary steps in supporting recovery (Aghakhani et al., 2011).

Fear, anxiety and depression may accompany the physical symptoms, making thus difficult the

patient’s optimal recovery (Watkins et al., 2013;Kala et al., 2016). In such cases, disease self-

management approaches are especially relevant to the particular needs of cardiac patients who need to

adapt to disease restrictions.

When their health status changes, patients are facing with disruption of daily routines and they

need a transition period toward rebuilding professional self. Occupational therapists can respond best at

these transitions and, recognizing the key role of occupations as facilitator, are very suitable for the whole

team of cardiac rehabilitation (Feroni & Thielke, 2010). Despite proven positive effects of occupational

therapy, there are still little referral in the rehabilitation practice after myocardial infarction (Wells, 2007;

Drosselmeyer et al., 2014; Che Daud et al., 2016).

A classic cardiac rehabilitation program involves monitored physical activity and therapeutic

education for lifestyle changes. In addition to this, occupational therapy can maximize the benefits of

cardiac patient’s recovery, especially through supervised occupational engagement (Proudfoot, 2006).

The occupational therapist focuses on the impact of the physical activity restrictions on significant

occupations for the patient, such as work, self-care and leisure. In the same time he brings guidance,

reassurance and practical options for the patient to resume his valuable occupations and to implement the

physical activity prescriptions at home.

Methodology

Our research was based on the case study on a man aged 54 years, who recently suffered a

myocardial infarction. For a logical and coherent working approach, we used the Canadian Practice

Process Framework (CPPF), which provides a helpful framework for developing and implementing

effective occupational therapy interventions (Cole & Tufano, 2008).

Designed to be used by occupational therapists, COMP questionnaire helps to identify the

occupational problems of the client and to detect changes in self-perception of occupational performance

and satisfaction scores, using a 10-point rating scale, where 1 equals poor performance and low

satisfaction, while 10 means very good performance and high satisfaction (Law et al., 1990).

The Borg Rating of Perceived Exertion (RPE) scale is a valid and frequently used instrument for

subjective evaluation of exercise intensity, recommended especially to elderly and cardio-pulmonary

patients in the first weeks of resuming physical activity (Borg, 1982; Buckley, Sim & Eston, 2009).

Individuals are first thought to identify their body sensations and reactions during physical effort and then

to associate its value. Borg proposes a grading scale effort from 6 to 20, respectively from very, very light

to very, very hard.

We wanted to measure also the presence of general symptoms of anxiety commonly occurring in

cardiac disease. For this reaseon we esed the Depression Anxiety Stress Scale (DASS), which was

developed by researchers at the University of New South Wales and it provides a broad coverage of

general symptoms of anxiety, depression and stress (UNSW, 1995). We used the short form (DASS 21),

which is a 21 item (from 42) self-report questionnaire, where individual is required to indicate the

presence of a symptom over the previous week.

DASS-anxiety focuses on physiological arousal, perceived panic, and fear. Each item is scored

from 0 (did not apply to me at all over the last week) to 3 (applied to me very much or most of the time

over the past week), in the end resulting five intervals of outcome interpretation: 0-7 normal level of

anxiety, 8-9 mild anxiety, 10-14 moderate, 15-19 severe and over 20 extremely severe anxiety (Lovibond

& Lovibond, 1995).

The DASS has excellent psychometric properties (reliability, validity and specificity) and few

limitations, however clinicians should be aware that certain patient groups (eg. children, developmentally

delayed, or those who are taking certain medications) may have difficulty understanding the questionnaire

items (Buckley, Sim & Eston, 2009).

Results

Our research is based on the case study of a man, aged 54 years, who suffered an acute myocardial

infarction three weeks ago. From his medical history we found that he was diagnosed with chronic

ischemic cardiopathy, ten years ago. He also suffers from hypercholesterolemia and grade I obesity, but

he is normotensive. The myocardial infarction occurred during his working program and the prompt

reaction of his colleagues has enabled the emergency measures of paramedics’ team. He was diagnosed

with acute anteroseptal myocardial infarction, for which he received emergency treatment in the intensive

care unit. He was discharged from hospital after two weeks with a relative good general health. The

results after performing coronary angiography were also good. Following the positive evolution of initial

diagnosis, the cardiologist recommended a conservative approach, meaning ambulatory pharmacological

treatment (coronary vasodilators, lipid-lowering drugs and anticoagulants) and also medical leave for

three months.

Our patient had history of hypertension on maternal side and he used to smoke more than one

package of cigarettes in a day, for twenty years, but he quit six years ago. Occasionally he drinks any

alcoholic beverage. He works as electrician in a car factory, one of the most important in the town where

he lives and in the country as well. The patient is proud been doing this job for more than 20 years and he

feels very attached to his team and to the working environment in general, which he considers as the

second home. His wife is now working overtime to meet the family economic needs, and after discharge

he must do alone with household chores and everything else needed. He likes to be involved in household

maintenance and to help his wife, but the greatest wish is to regain his physical fittness as soon as

possible and to return to work. However, he is aware that although independent in all occupations, he gets

tired very quickly and even fears of the possibility of a new cardiac episode, triggered by too intense

effort or emotional stress.

The patient had marked limitation in physical activity and proved an appropriate understanding of

the cardiac event he suffered, and also of the secondary prevention measures that must be taken, in order

to reduce his comorbid risk factors (obesity and high blood cholesterol).

Considering all these aspects and the time elapsed from hospital discharge, we created a six weeks

out-patient program that adopts a self-management approach for the phase II of cardiac rehabilitation.

Physical activity and education components were supplemented with opportunities for supervised

occupational engagement within the patient’s home environment.

Our patient participated in therapeutic education sessions focused on such things as improving

dietary habits, motivation, reconditioning the cardiovascular system and safely regaining functional

recovery.

Since the occupation plays a critical role in patient’s recovery and wellbeing on multiple levels, it

is important to determine the fit between the person, the environment and meaningful occupations by the

extent of how patient’s functional capacity match his environment and specific occupation requirements.

As the patient expressed concerns with respect to a wide range of occupations, the COPM was

applied to determine their hierarchy in influencing the patient’s wellbeing. He identified that mobility

outside the home (performance score 2, satisfaction score 2), being able to participate in discussions on a

social network (performance score 1, satisfaction score 1) and participating in housekeeping

(performance score 3, satisfaction score 4) are the main occupational issues that he would like to improve.

Together, we established these as goals for the occupational therapy intervention.

The Person-Environment-Occupation (PEO) practice model was used as intervention tool for

guiding us in establishing the SMART objectives of our intervention plan. They are the result of the

extent in which the patient’s functional capacity and environment characteristics fit the selected

occupations’ requirements. Thus, we agreed that after six weeks, the patient will be able to accompany

his wife to shopping in the neighbourhood,he will daily show interest and motivationto check his new

social network account and he will be able to perform housekeeping tasks for more than half hour/day,

without feeling physical exertion.

The occupational therapy program focused on daily engaging the patient in functional activities

(walking, dressing, cleaning the house) starting with 15 minutes sessions initially, then progressively

rising them to 30 minutes by the end of the intervention period. For each session we recommended 5

minutes of warming up and then 5 minutes of cooling down, in order to satisfy the physiological bases for

functional adaptations. At the end of each occupational therapy session, we had included 10-15 minutes

of therapeutic education (free discussions, information, presentation of didactic materials, brochures,

flyers, therapeutic guides, videos etc.). Considering the fact that the patient had a good level of

understanding and also a high motivation for change, we set a frequency of three therapeutic sessions/

week in his home environment.

Also, to enhance self-efficacy, we assisted the patient to monitor his heart rate (HR) and rate of

perceived exertion (RPE) following each task of the occupations needs to perform, and record the

outcomes at the beginning and at the end of the activity, in a structured way, which then formed the basis

for discussions. All demanding activities were graded and monitored according to patient’s RPE and he

was taught how to incorporate them into his daily occupations. The presence of emotions associated with

anxiety were assessed too, using DASS 21 self-questionnaire, initially and then at the end of the OT

intervention program.

After six weeks, the improvement of performance and satisfaction of the identified problems was

significant for all three items, the patient reporting higher scores at final administration of COPM

questionnaire, as shown in table 1 .

There is an overall change of 3.3 points for performance and 5.3points for satisfaction. It is

obvious that the most important contribution to these positive results is due to the increase in ambulatory

performance, which, not surprisingly, gives also the highest satisfaction to our patient.

Also the patient’s functional progress is reflected by the improvements of RPE and anxiety level

after the final evaluation (Table 2 ). The change in RPE perception for the most important physical

activity demanding tasks (walking outside the home and housekeeping) was of 5 points decrease, which

actually reflects a 25% progress of the patients’ physical capacity to maintain a dynamic occupation.

Discussions

The results of our intervention reflected positively not only on occupations engagement of the

patient, but also in his healthy dietary habits, weight control and decreased level of anxiety.

The current trend of cardiovascular rehabilitation is to include comprehensive, evidence-based

interventions and to influence health behaviour changes. Most often, patients who have suffered a cardiac

episode, and generally, those with chronic diseases would like the most to resume their professional

activity in the shortest time (Servey & Stephens, 2016). However, there are other more important areas

that contribute to functional independence (self-care, physical endurance, lifestyle changes, energy

conservation, and stress management) and which further can sustain their socio-professional

reintegration.

Male participation in family life seems to depend on holding a job, succeeding in work, conferring

a sense of protection and safety, and uncertainty of maintain these roles after illnesses can induce and

maintain anxiety (Mampuya, 2012). For our patient, marriage seems to provide the necessary social

support that enhances his sense of control, which in turn helps him to deal with the disease.

Overall, more evidence supports the useof physical activity and occupation engagement in

reducing stress, with a tendency for improvements in social and emotional aspects for those who practice

it regularly (Taheri & Irandoust, 2014). Also, emerging evidence from preliminary studies has supported

that attendance in secondary prevention programs is a safe method to increasing a patient’s functional

capacity (Rogers et al. 2016).

The results that we obtained confirm the validity of the proposed occupational therapy program in

the clinical context which we presented, providing thus the evidence of outpatient applicability of this

type of intervention in cardiac patient with a recent history of myocardial infarction.

Conclusions

After the end of the acute phase, all cardiac patients should be able to follow a multidisciplinary

rehabilitation program. Many barriers affect the adherence to secondary preventive measures. Gender,

age, socio-economic status, and ethnic minorities are all some of the factors related to lack of

participation. The strategies based on home interventions can remove these barriers, so that all patients

can benefit from equal opportunities in getting the best care possible. These programs aim to maintain the

patient’s motivation for lifestyle change, while the application of occupational therapy services can

amplify the benefits of modern healthcare interventions. Moreover, occupational therapy in cardiac

rehabilitation addresses to development of life-skills in order to improve an individual’s recovery after a

life altering cardiac event. Nutrition counselling and therapeutic education are also keys to improving a

cardiac patient’s health.

The patient needs constantly renewed attention to his emotional, social and professional problems

and to develop his motivation towards the effort required during recovery. The entire process is carried

out respecting the principles of client-cantered practice, which means developing a partnership between

the patient and therapist to facilitate the participation, satisfaction and sense of self-efficacy from the

patient. The expanding of clinical research on occupational therapy utility in post myocardial infarction

patient represents an important research direction in this domain, considering the possibility of providing

to patients reliable alternatives for early recovery through accessible, non-pharmacological methods.

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